By Dr. Nahid Aziz

Over 25 years of war and conflicts have left Afghanistan and its people with devastating psychological consequences. The wars caused Afghanistan's population to be demoralized and to suffer socially and economically. One direct social consequence has been the destruction of the Afghan social and family structures that had served Afghans over time, especially Afghan women, as the foundation for sustaining psychological well-being.

In addition, many years of direct exposure to aggression, violence, and continuous fear have adversely affected the mental health of Afghan women. They suffer from high prevalence of psychological disorders. According to the World Health Organization, (WHO, 2001), it is estimated that more than five million Afghan women and men suffer from various types of mental distresses, including post traumatic stress disorder (PTSD), depression, anxiety disorders, and substance abuse and dependence. For a country with a population of 28 million, this is especially alarming.

Despite limited epidemiological studies on the occurrences of mental illnesses, it has been observed that Afghan women disproportionally suffer from psychological illnesses. This is due in part to their systematic exclusion from education, employment, and political participation through strict gender segregation under the Taliban regime. They were mainly confined at home, and often deprived of their basic human rights. In addition, different forms of violence against Afghan women, such as forced marriage, under-age marriage, sex trafficking, and physical and domestic violence have caused mental distress for Afghan women.

Although studies on the condition of mental health in Afghan women have been scarce, a few limited studies suggest that Afghan women suffer mainly from depression, PTSD, and other anxiety disorders (Razekh, 1999; Lopez Cordozo, 2004; Scholte et al. 2004).

But a lack of mental health professionals and culturally sensitive assessment tools and knowledge has created barriers to accurately assess and treat mental disorders in the population, especially in Afghan women, who live under strict gender segregation imposed by cultural norms. In fact, the 2006 WHO report indicates that in Afghanistan the number of qualified mental health practitioners is almost non-existent. According to this report, for the entire country, there are currently only a total of 8 psychiatrists, 18 psychiatric nurses, and 20 mental health professionals for a population of 28 million (WHO, 2006).

Mental Health Indicators for Afghan Women

Overall, a review of a number of reports point to the following mental health conditions of Afghan women (AIHRC, 2006; van de Put, 2002; Miller et al, 2004):

•  Suicide rates and self-immolations among Afghan women and girls have dramatically increased. There are few treatment services for affective disorders, stress and other psychological disabilities.

•  One report concludes that 98% of Afghan women suffer from PTSD, Major Depression, or severe anxiety (Razekh et al, 1999).

•  Afghan Independent Human Rights Commission g7hreports that disabled Afghan women are more vulnerable to being socially isolated and marginalized. Thus, it is not uncommon that many disabled Afghan women go through the experience of being discriminated against twice (AIHRC, 2006).

•  Mental health needs of Afghan women have not received adequate attention from the aid community and NGOs.

•  There is an acute lack of services for people with learning disabilities, and a lack of trained women rehabilitation workers makes treatment even less accessible to women, for whom cultural barriers prevent treatment by male workers.

•  There are scarce international and local programs addressing domestic violence. In particular, there are no known projects or programs at all in remote areas, where Afghan women are more vulnerable.

•  There is a high rate of female drug users in Afghanistan , who often use opium to self-treat for trauma, insomnia, and other problems. Women face barriers to treatment due to stigmatization of female drug users. Economic considerations and a lack of child-care in rehabilitation facilities also prevents women from getting the mental health help they need.

•  Violence against women, including physical, sexual, and psychological, is pervasive within Afghan society, affecting an overwhelming majority of women and girls. The violence is usually committed by a direct family member, sometimes female family members, and consistently by someone the victim knows.

•  Violence against women and “honor” crimes are considered taboo subjects, and thus not widely reported to the police. There are estimates of as many as 5,000 unreported cases a year. But in reality this number may be much higher. Typically, the violence is committed by males, mainly family members who often receive the indirect support of community leaders (AIHRC, 2006).

•  The courts have many shortcomings, including lack of well-trained judges and inadequate enforcement mechanisms, and as a result are not adequately protecting women under Afghan law. There are many cases with female victims who are unlikely to make it past the verdict rendered by local tribal councils. The Afghan judges and court officials are more likely to accept harm to women as a sentence for actions such as infidelity.

Making Mental Health Needs of Afghan Women a Priority: What Needs To Be Done?

•  There is a great need for epidemiological studies on the occurrences of psychological disorders in Afghanistan, especially among Afghan women.

•  In order to protect victims of domestic violence and other violence against women, culturally and socially appropriate shelters and safe havens must be developed and protected.

•  Afghan women need social advocates who can advocate on their behalf in Afghanistan and in the West.

•  There is a great need for research to demonstrate the impacts of psychosocial interventions on mental health of Afghan women. This could eventually influence the formation of the path to peace and reconciliation.

•  General awareness must be raised among Afghans of the relationship between post-conflict mental and psychosocial disorders and how these can have a direct impact on the health and education of their children.

•  Supported by such awareness, the investment in the mental and psychosocial well being of women should be much increased. This is essential, as it is women who most influence the health, nutrition, and education of their children, and consequently, the nation.

•  Long-term peace, security and the guarantee of basic human rights for Afghan women are the most critical factors to achieve mental health. However, meeting the very basic needs (shelter, food, running and clean water, etc.) would not only improve the physical health of many Afghans – women, men, and children – but also their mental condition.

Nahid Aziz, Psy.D., is a member of PsySR's new Peacebuilding and Reconciliation Action Committee and an Associate Professor in the Clinical Psychology Department at Argosy University , Washington , D.C.  She is a member of the Afghanistan Mental Health Workgroup at the U.S. Substance Abuse Mental Health Services Administration (SAMHSA), which provides technical assistance to Afghanistan 's Ministry of Public Health to reconstruct mental health services and develop mental health capacities. This is Part Two of a series.